I. Introduction
The Department, the Community Services Boards and Behavioral Health Authority (CSB) are committed to a collaborative continuous quality improvement (CQI) process aimed at improving the quality, transparency, accessibility, consistency, integration, and responsiveness of services across the Commonwealth pursuant to Code §37.2-508(C) and §37.2-608(C). Exhibit B establishes the CQI framework through which CSBs, providing community behavioral health services, and the Department engage in the CQI processes that are established to track progress towards meeting established benchmarks, identify barriers to achievement, and understand and address root causes that impacts progress. For the purposes of this Exhibit, “benchmark” is defined as the measure target for achievement that is established by the Department.
II. Benchmarks
The establishment of benchmarks is a collaborative process with the CSBs and exists as part of the Department’s Behavioral Health Measure Development and Review process.
III. Technical Assistance
An opportunity for technical assistance exists when a CSB requires support in meeting an established goal. The following graduated response will be employed to support the CSB to achievement.
Technical Assistance (TA)
For the purposes of this Exhibit, technical assistance (TA) is defined as targeted, collaborative support provided
by the Department to CSBs for the purposes of improving performance on the core measures outlined in Section V of this exhibit. The Department may initiate the process for its provision of TA when a CSB’s performance does not meet the benchmark. Upon receipt of Department notification of the requirement for CSB participation in TA, the CSB shall respond to the Department within 10 business days to confirm receipt and establish next steps.
Additionally, TA may be requested by the CSB at any time. A CSB may request TA from the Department by completing the Exhibit B TA Request form. The Department shall respond to the CSB request for TA within 10 business days to confirm receipt and establish next steps.
The Department will work to address CSB-raised concerns or identified Department data issues as part of the technical assistance process.
IV. Performance Monitoring
A. Performance Improvement Plan (PIP)
(1) In the event the TA does not result in improvement, the Department and the CSB will work collaboratively to develop a Performance Improvement Plan (PIP). For the purposes of this Exhibit, a PIP is defined as a written, collaborative agreement between the Department and the CSB that identifies specific action steps required to support the CSB in meeting identified benchmarks for core performance measures as outlined in Section V of this exhibit.
(2) A PIP will not be entered into until at least 6 months of TA has been provided in order to allow for the review of at least 2 quarters of data. At a minimum, a PIP will include activities to be completed, timelines for completion of each activity, parties responsible for completion of each activity, and goals that are specific, measurable, achievable, relevant, and timebound (SMART).
B. Corrective Action Plan (CAP)
In the event PIP implementation does not result in improvement regarding core performance measures pursuant to Section V of this exhibit; the Department may seek other remedies as outlined in the Compliance and Dispute Resolution Process section of the performance contract such as initiating a CAP. For the purpose of this Exhibit, a CAP is defined as a written plan to address noncompliance with identified benchmarks for core performance measures outlined in Section V of this exhibit. The Department may also find it necessary to enter into a CAP with the CSB in circumstances where the severity of the issue(s) is determined to be necessary for a CAP versus a PIP. If the CSB refuses to participate in the TA and/or PIP process, a CAP will be initiated by the Department. If the CSB disagrees with the CAP they shall utilize the Compliance and Dispute Resolution Process of the performance contract.
V. Performance Measures
CSB Core Performance Measures: The CSB and Department agree to use the CSB Core Performance Measures, developed by the Department in collaboration with the VACSB Data Management, Quality Leadership, and VACSB/DBHDS Quality and Outcomes Committees (Q&O) to monitor outcome and performance measures for the CSBs and improve the performance on measures where the CSB falls below the benchmark. These performance measures include:
A. Suicide Screening Measure: Percentage of youth (ages 6-17) and adults (age 18 or over) and have a new MH or SUD case open who received a suicide risk assessment completed within 30 days before or 5 days after the case opening.
Benchmark: The CSB shall conduct a Columbia Suicide Severity Rating Scale screening for at least 86 percent of individuals with a new MH or SUD case opening.
B. Same Day Access Measures: Percentage of individuals who received a SDA assessment and were determined to need a follow-up service who are offered an appointment for a service within 10 business days and attend a scheduled follow-up appointment within 30 calendar days.
Benchmark: The CSB shall offer an appropriate follow-up appointment to at least 86 percent of the individuals who are determined to need an appointment; and at least 70 percent of the individuals seen in SDA who are determined to need a follow-up service will return to attend that service within 30 calendar days of the SDA assessment.
C. SUD Engagement Measure: Percentage of individuals 13 years or older with a new episode of substance use disorder services as a result of a new SUD diagnosis who initiate services within 14 days of diagnosis and attend at least two follow up SUD services within 30 days.
Benchmark: The CSB shall aim to have at least 50 percent of SUD clients engage in treatment per this definition of engagement.
D. DLA-20 Measure: 6-month change in DLA-20 scores for youth (ages 6-17) and adults (age 18 or over) receiving outpatient services in mental health program areas.
Benchmark: At least 35%of individuals receiving 310 Outpatient Services in Program Area 100 scoring below a 4.0 on a DLA-20 assessment will demonstrate at least 0.5 growth within two fiscal quarters.
VI. Additional Expectations and Elements Being Monitored
The data elements and expectations of this section were put into place prior to the data quality and benchmarking review process as of March 1, 2022 and are active expectations regarding CSB operations and implementation. The process for technical assistance, performance improvement plans, and corrective action plans as described in Section III and IV of this exhibit does not apply to this section. The Department in collaboration with the VACSB Data Management, Quality Leadership, and VACSB/DBHDS Quality and Outcomes Committees will monitor outcome and performance measures in this section for relevance with the CQI process and propose revisions as needed.
A. Outpatient Primary Care Screening and Monitoring
- Measures – CSB and DBHDS will work together to establish.
- Benchmark – CSB and DBHDS will work together to establish.
- Outcomes – To provide yearly primary care screening to identify and provide related care coordination to ensure access to needed physical health care to reduce the number of individuals with serious mental illness (SMI), known to be at higher risk for poor physical health outcomes largely due to unidentified chronic conditions.
- Monitoring- CSB must report the screen completion and monitoring completion in CCS monthly submission to reviewed by the Department.
B. Outpatient Services
Outpatient services are considered to be foundational services for any behavioral health system. Outpatient services may include diagnosis and evaluation, screening and intake, counseling, psychotherapy, behavior management, psychiatry, psychological testing and assessment, laboratory, and ancillary services.
- Measures – Expertise in the treatment of trauma related conditions is to be established through training.
- Benchmark – CSB should provide a minimum for outpatient behavioral healthcare providers of 8 hours of trauma focused training in treatment modalities to serve adults, children/adolescents and their families within the first year of employment and 4 hours in each subsequent years or until 40 hours of trauma focused treatment can be demonstrated.
- Monitoring: Provide training data regarding required trauma training yearly in July when completing evidence-based practice survey.
C. Service Members, Veterans, and Families (SMVF)
Training
- Measures – Percentage of CSB direct services staff who receive military cultural competency training
- Benchmark – Provided to 100% of CSB staff delivering direct services to the SMVF population within 90 days of hire and every 3 years. Direct services include, but are not limited to, those staff providing crisis, behavioral health outpatient and case management services.
Presenting for Services
- Measures – Health records in all program areas will contain a valid entry for Military Status demographic variable in CCS.
- Benchmark – 90% of individuals will have a valid entry.
Referral Destination
- Measures – Percentage of SMVF clients served who are given information about referral services to SMVF referral destinations.
- Benchmark – 70% of SMVF in CSB services will receive information about services offered by Military Treatment Facilities, Veterans Health Administration facilities, and/or Virginia Department of Veterans Services; and be supported in being referred at the individual’s request.
Columbia Suicide Severity Rating Scale
- Measure – SMVF individuals in CSB services will be screened for suicide risk at intake (and as needed per agency clinical protocols to monitor risk level) utilizing the Columbia Suicide Severity Rating Scale (C-SSRS) brief screen.
- Benchmark – Conducted for 86% of SMVF individuals beginning in FY23 (July 1, 2022).
- Monitoring – CSB must report all data through its CCS monthly submission.
D. Peer and Family Support Services
Peer Support Service units (15-minute increments)
- Measure: Total number of Peer Support Service units (15-minute increments) provided will increase annually for individual and group.
- Benchmark: Total number of Peer Support Service units (15-minute increments) provided will increase 5% annually (only applies to service codes and locations where Peer and/or Family Support Services are delivered). Year 1 will allow for a benchmark and this percentage will be review going into year two for individual and group.
Peer FTEs
- Measure: Total number of Peer Support Service staff offering peer support services in mental health and/or substance use treatment settings.
- Benchmark: Year 1 will allow for monitoring and benchmarking.
E. DLA-20 Measure:
- Measure: 6-month change in DLA-20 scores for youth (ages 6-17) and adults (age 18 or over) receiving outpatient services in substance use disorder program areas.
- Benchmark: At least 35%of individuals receiving 310 Outpatient Services in Program Areas 300 scoring below a 4.0 on a DLA-20 assessment will demonstrate at least 0.5 growth within two fiscal quarters.